CCHI Mini-Glossary Project Glossary #4

Subject: Affordable Care Act - Insurance

Language: Spanish
Note: Some terms and definitions are from the Benefits and Coverage Uniform Glossary by Centers of Medicaid and
Medicare Services (See: http://www.cms.gov/cciio/Resources/forms-reports-and-other
resources/index.html#Summary%20of%20Benefits%20and%20Coverage%20and%20Uniform%20Glossary).
# English Spanish Translation Definition

1. Affordable Care Ley del Cuidado de la The comprehensive federal health care reform
law enacted in March 2010.
Act (ACA) Salud (ACA); Ley de
Syn. Health Care Cuidado de Salud a Bajo
Reform; Precio (ACA) (de
Obamacare healthcare.gov)
Syn. Reforma del Cuidado
de la Salud;
Obamacare

2. Health Insurance Seguro médico; A contract that requires an individual’s health

insurer to pay some or all of their health care
aseguranza (común en
costs in exchange for a premium.
Estados Unidos en de la
comunidad mexicana/oeste
del país)

3. Health Insurance Mercado de seguros State- or federally run and regulated market where
an individual can shop, compare, and buy health
Marketplace médicos Syn. Intercambio
care coverage.
Syn. Exchange

4. Eligibility requirements Requisitos de elegibilidad Conditions that must be met in order for an
individual or group to be considered eligible for
insurance coverage.

5. Open enrollment (Período de) inscripción A period of time each year when an individual
can purchase or change health coverage.
(period) abierta

6. Medicaid Medicaid Health insurance provided by the government to

some low-income people, families and children,
pregnant women, the elderly, and people with
disabilities. In some states the program covers all
adults below a certain income level. Medicaid
programs must follow federal guidelines, but
coverage and costs may be different from state to
state.

7. Children’s Health Plan de Seguro Médico Health insurance provided by the government
to children in families that earn too much
Insurance Program para Niños (CHIP)
money to qualify for Medicaid. In some
(CHIP) states, CHIP covers parents and pregnant
women. Each state works
closely with its state Medicaid program. In
many cases, if an individual qualifies for
Medicaid your children will qualify for either
Medicaid or CHIP.

8. Medicare Medicare A federal health insurance program, administered

by the Social Security Administration, that
 provides health care for most people over 65 and
certain other eligible individuals.

9. Health plan Plan médico A benefit an individual’s employer, union or

other group sponsor provides to that individual
to pay for their health care services.

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10. Secondary coverage Cobertura secundaria When a person is covered under more than one
health insurance plan, this term describes the
health insurance plan that provides payment on
claims after the primary coverage (i.e. main plan).

11. Managed care Cuidado administrado A general term used to describe a variety of health
care and health insurance systems that attempt to
Atención administrada
guide a patient’s use of benefits, typically by
requiring that a patient coordinate his or her
health care through a primary care physician, or by
encouraging the use of a specific network of
healthcare providers. The management of health
care is intended to keep costs -and monthly
premiums- as low as possible. Examples of
managed care plans include:
∙ Health maintenance organizations
(HMOs), ∙ Preferred provider
organizations (PPOs),
∙ Exclusive provider organizations (EPOs),
and ∙ Point of service plans (POSs).

12. Premium Prima The amount that must be paid for an individual’s
health insurance or plan. The individual and/or
their employer usually pay it monthly, quarterly
or yearly.

13. Dependent Dependiente A spouse, child, or domestic partner who is

covered under a policyholder or subscriber’s plan,
depending on applicable law and the plan’s terms
and conditions.

14. Covered services Servicios cubiertos Health care services that are included in and paid
for by an individual’s health insurance or plan.

15. Excluded services Servicios excluidos Health care services that an individual’s
health insurance or plan doesn’t pay for or
cover.

16. Pre-existing condition Condición preexistente A medical condition that a person has before
being enrolled in a health plan.
Problema preexistente
Trastorno preexistente

17. Service area Área de servicio The geographic area in which a health insurance
plan’s benefits are made available. Some health
área de cobertura
insurance plans will not provide coverage outside
of a plan’s service area.
 18. Network Red (de cobertura) The facilities, providers and suppliers an
individual’s health insurer or plan has contracted
with to provide health care services.

19. Provider Proveedor A physician (M.D.– Medical Doctor or D.O.– Doctor

of Osteopathic Medicine), health care professional
or health care facility licensed, certified or
accredited as required by state law.

20. Primary Care Proveedor de atención A physician (M.D. – Medical Doctor or D.O.– Doctor
of Osteopathic Medicine), nurse practitioner,
Provider/ Physician primaria (PCP);
clinical nurse specialist or physician assistant, as
(PCP) Proveedor principal de allowed under state law, who provides,
atención a la salud coordinates or helps a patient access a range of
(PCP); médico de health care services.
cabecera;
médico principal

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21. Specialist Especialista A physician specialist focuses on a specific area of
medicine or a group of patients to diagnose,
manage, prevent or treat certain types of
symptoms and conditions. A non-physician
specialist is a provider who has more training in a
specific area of health care.

22. Preferred provider Proveedor preferido (de A provider who has a contract with an individual’s
health insurer or plan to provide services to them at
healthcare.gov);
a discount. Health insurance plans can have a
proveedor preferente “tiered” network, meaning the individual must pay
(también usado) extra to see some non-preferred providers.

23. Participating provider Proveedor participante Generally, this term is used in a sense synonymous
with Network Provider. However, not all healthcare
providers contract with health insurance companies
at the same level. Some providers contracting with
insurers at lower levels may sometimes be referred
to as "participating providers" as opposed to
"preferred providers."

24. Non-preferred Provedor no preferido A provider who doesn’t have a contract with an
individual’s health insurer or plan to provide
provider
them with services. The individual pays more to
see a non preferred provider.

25. Cost share Costo compartido The portion of charges for a service or
prescription that an individual is responsible for
paying, such as a copayment, coinsurance, or
deductible payment.

26. Co-insurance Coseguro An individual’s share of the costs of a covered

health care service, calculated as a percent (for
example, 20%) of the allowed amount for the
service. The individual pays co-insurance plus any
owed deductibles.

27. Co-payment Copago A fixed amount (for example, $15) an individual

 pays for a covered health care service, usually
when they receives the service. The amount can
vary by the type of covered health care service.

28. Deductible Deducible The amount an individual owes for health care
services their health insurance or plan covers before
the individual’s health insurance or plan begins to
pay. For example, if an individual’s deductible is
$1000, their plan won’t pay anything until they’ve
met their $1000 deductible for covered health care
services subject to the deductible.

29. Allowed amount Cantidad aprobada; Maximum amount on which payment is based for
covered health care services. If the individual’s
Syn. Eligible Monto permitido
provider charges more than the allowed amount,
expense; Payment Syn. Gasto elegible; the insured may have to pay the difference.
allowance; Subsidio de pago;
Negotiated rate Tarifa negociada/ Costo
negociado

30. Usual, Customary, Cargo Usual, The amount paid for a medical service in a
geographic area based on what providers in the
Reasonable (UCR) Acostumbrado, y
area usually charge for the same or similar medical
charge Razonable (UCR) service. The UCR amount sometimes is used to
determine the allowed amount.

31. Balance billing Saldo facturado When a provider bills an individual for the
difference between the provider’s charge and the
allowed amount. For example, if the provider’s
charge is $100 and the allowed amount is $70, the
provider may bill the individual for the remaining
$30.

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32. Out-of-pocket costs Gastos de su bolsillo Any amounts an individual pays for covered
services, not including their monthly premiums.

33. Out-of-pocket limit Límite de gastos de su The most an individual pays during a policy period
(usually a year) before their health insurance or
Syn. Out-of- bolsillo Syn. Máximo de
plan begins to pay 100% of the allowed amount.
pocket gastos de su bolsillo This limit never includes the premium, balance-
maximum billed charges or health care the individual’s health
insurance or plan doesn’t cover.

34. In-network payments Pagos a proveedores Payments (co-insurance, co-payment) for covered
health care services to providers who contract with
dentro de la red
an individual’s health insurance or plan.

35. Out-of-network Pagos a proveedores fuera Payments (co-insurance, co-payment) for covered
health care services to providers who do not
payments de la red
contract with an individual’s health insurance or
plan. Out-of network payments are usually high
than in-network ones.

36. Medically necessary Clínicamente necesario; Health care services or supplies needed to
prevent, diagnose or treat an illness, injury,
Médicamente necesario;
condition, disease or its symptoms and that meet
 Necesario por razones accepted standards of medicine.
médicas (de healthcare.gov)

37. Preauthorization Preautorizado A decision by an individual’s patient’s health insurer

or plan that a health care service, treatment plan,
Syn. Prior Syn. Autorizado
prescription drug or durable medical equipment is
authorization; previamente Certificado medically necessary. The health insurance or plan
prior approval; previamente may require preauthorization for certain services
precertification before the individual receives them, except in an
emergency. Preauthorization isn’t a promise an
individual’s health insurance or plan will cover the
cost.

38. Grievance Queja A complaint that an individual communicates to

their health insurer or plan.

39. Appeal Apelación A request by an individual to their health insurer

or plan to review a decision or a grievance
again.

40. Physician services Servicios médicos; Health care services a licensed medical physician
(M.D. – Medical Doctor or D.O. – Doctor of
Servicios del médico
Osteopathic Medicine) provides or coordinates.

41. Ambulatory care Cuidado ambulatorio; Medical care provided on an outpatient basis
which may include diagnosis, certain forms of
Cuidado a pacientes
treatment, surgery and rehabilitation.
ambulatorios;
Atención ambulatoria

42. Hospitalization Hospitalización; Care in a hospital that requires admission as an

inpatient and usually requires an overnight stay.
Internación
An overnight stay for observation could be
outpatient care.

43. Hospital Cuidado hospitalario a Care in a hospital that usually doesn’t require
an overnight stay.
Outpatient Care pacientes externos;
Atención ambulatoria en
el hospital;

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Atención a pacientes
ambulatorios en el hospital

44. Prescription drug Cobertura de las recetas Health insurance or plan that helps pay for drugs
and medications that by law require prescription.
coverage médicas [de
healthcare.gov];
Cobertura de medicinas
con receta médica;
Cobertura de
medicamentos
despachados con receta
 45. Emergency Condición/enfermedad An illness, injury, symptom or condition so serious
that a reasonable person would seek care right
medical médica de emergencia;
away to avoid severe harm.
condition Problema médico de
emergencia

46. Emergency room care Cuidado de Emergency services an individual gets in an

emergency room, i.e. Evaluation of an emergency
emergencias; Servicios
medical condition and treatment to keep the
de la sala de condition from getting worse.
emergencias
Atención en la sala de
emergencias

47. Emergency Trasporte médico de Ambulance services for an emergency

medical condition.
medical emergencia;
transportation Traslado por
emergencia médica

48. Urgent care Cuidado urgente; Care for an illness, injury or condition serious
enough that a reasonable person would seek care
Servicio de urgencias
right away, but not so severe as to require
emergency room care.

49. Chronic disease Manejo/ Gestión de Health care provided to patients with chronic
conditions such as diabetes, asthma, heart
management enfermedades crónicas
disease, depression, etc.

50. Long-term care Servicios de atención a Care provided on a continuing basis for the
chronically ill or disabled. Long-term care may be
largo plazo;
provided on an inpatient basis (at a long-term care
Cuidado a largo plazo; facility) or in the home setting.
Atención a largo plazo

51. Nursing home Centro/Casa de A licensed facility which provides general nursing
care to those who are chronically ill or who require
convalecencia; Casa de
constant supervision and assistance with the needs
convalecencia; of daily living.
Asilo de ancianos;
residencia de personas
mayores

52. Palliative care Cuidado paliativo Specialized medical care for people with serious
illnesses. It focuses on providing patients with relief
from the symptoms, pain, and stress of a serious
illness—whatever the diagnosis. The goal is to
improve quality of life for both the patient and the
family.

53. Preventive care Cuidado preventivo Health services provided to prevent diseases (or
injuries) rather than curing them or treating
Syn. Preventive & Syn. Servicios preventivos y
their symptoms. Examples include routine
wellness services de bienestar general examinations and immunizations.

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54. Annual physical Examen médico anual; A yearly medical examination by a physician or
 examination Revisión médica anual nurse practitioner to determine the state of a
person’s health, identify risk factors for disease,
Syn. Routine Syn. Examen físico de and devise strategies for disease prevention.
physical; Annual rutina; Chequeo anual
check-up

55. Maternity and Cuidado prenatal y del Health care for pregnant women and newborns.
newborn care recién nacido;
Atención médica del
embarazo y recién nacidos

56. Mental health Servicios de salud Care provided for people with mental illnesses
and those who are at-risk.
services Syn. mental Syn. Sevicios
Behavioral health de salud
services conductual

57. Substance use Servicios para trastornos Care provided to people with addictions
and substance use problems.
disorder services del uso de sustancias;
Servicios para trastornos
de adicción;
Servicios para el abuso
de sustancias

58. Home health care Atención a la salud en el Health care services a person receives at home.
hogar;
Cuidados de salud en el hogar

59. Skilled nursing care Cuidados de enfermería
especializada;
Atención de enfermería
especializada
Services from licensed nurses in an individual’s
own home or in a nursing home. Skilled care
services are from technicians and therapists in
their own home or in a nursing home.

60. Rehabilitation services Servicios de rehabilitación Health care services that help a person keep, get
back or improve skills and functioning for daily
living that have been lost or impaired because a
person was sick, hurt or disabled. These services
may include physical and occupational therapy,
speech-language pathology and psychiatric
rehabilitation services in a variety of inpatient
and/or outpatient settings.

61. Habilitation services Servicios para recuperar
sus habilidades [de
healthcare.gov]
Health care services that help a person keep, learn
or improve skills and functioning for daily living.
Examples include therapy for a child who isn’t
walking or talking at the expected age. These
services may include physical and occupational
therapy, speech language pathology and other
services for people with disabilities in a variety of
inpatient and/or outpatient settings.

62. Physical therapy Terapia física; A form of rehabilitative care that uses specially
designed exercises and equipment to help
Fisioterapia
patients regain or improve their physical
abilities such as walking, the use of limbs, etc.

63. Occupational therapy Terapia ocupacional A form of therapy for those recuperating from
physical or mental illness that encourages
rehabilitation through the performance of activities
required in daily life.
 64. Speech-language Logopedia; A form of therapy for the improvement or cure of
communication disorders, including speech,
pathology Patología del habla- y lenguaje
language, and swallowing disorders.

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65. Hospice services Servicios para pacientes Services to provide comfort and support for persons
in the last stages of a terminal illness and their
terminales;
families.
Servicios de hospicio

66. Respite care Servicio de relevo en el Normally associated with hospice care, this service
is often made available for family members of a
cuidado del paciente
patient, providing the patient’s primary caretaker
with a break or respite from caring for the patient.
Respite care may be provided for the patient in
either the home or a nursing home setting.

67. Durable Medical Equipo médico duradero Equipment and supplies ordered by a health care
provider for everyday or extended use. Coverage
Equipment (DME) (DME)
for DME may include: oxygen equipment,
wheelchairs, crutches or blood testing strips for
diabetics.

68. Ancillary services Servicios auxiliares Supplemental healthcare services such as

laboratory work, x-rays or physical therapy that
are provided in conjunction with medical or
hospital care.

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